Red flag of bad therapy #9 : Insurance Fraud

Just a guess that many Mental Health Professionals out there who accept insurance have on occasion innocently billed incorrectly for sessions they’ve had with a client. As clients, and human beings, we understand “mistakes”, and providing you correct your error, it is only that …”an error” …and “no big deal” unless it continues to occur.

Here is Red Flag #9 : When a Therapist Commits insurance fraud!

Unfortunately you will rarely have this happen  until you’re well into your course of therapy! There is little you can do to prevent a therapist from double or triple billing you for sessions….but you can REPORT IT after it happens and then run from the alleged care of that therapist!

Do not try to work it out with the therapist!

The therapist was dishonest enough to commit fraud….it is very unlikely he/she is going to be honest with you and negotiate  “in good faith” to restore your sessions or return the money to the insurance company. Please…. believe me…I have been there! I made a deal to restore my sessions and the therapist “blew it off” and billed anyway.

You can read about that under my blog post “A Rude Awakening”
Here are a few common ways for a therapist (and other providers) to commit insurance fraud from the National Health Care Anti Fraud association website :

#’s 1,2,7,8,9 are more related to therapy than the others…

1.Billing for services that were never rendered—either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.

2.Billing for more expensive services or procedures than were actually provided or performed, commonly known as “upcoding”—i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying “inflation” of the patient’s diagnosis code to a more serious condition consistent with the false procedure code).

3.Performing medically unnecessary services solely for the purpose of generating insurance payments—seen very often in nerve-conduction and other diagnostic-testing schemes.

4.Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments—widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as “nose jobs” are billed to patients’ insurers as deviated-septum repairs.

5.Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary.

6.Unbundling – billing each step of a procedure as if it were a separate procedure.

7.Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.

8.Accepting kickbacks for patient referrals.

9.Waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan.

The main weapon to fight insurance fraud for an individual is awareness, and that includes:
1. knowing your insurance plans coverage..
2. checking your billing on line with the insurance company!…often therapy clients are not sent any sort of hard copy to check the billing
3. know what diagnosis your therapist is billing under
4. Confronting a therapist with any discrepancies!

5. REPORTING FRAUD if it does occur!

The most important thing you can do is leave the therapist’s so called treatment and then REPORT  the insurance fraud to the insurance company and your State Department of Insurance. If Medicare is involved, REPORT IT! to them! Also File a complaint with the Licening Board in your State against the therapist.


One Response

  1. […] This post was mentioned on Twitter by Mortgage Red Flag, Dana Brook. Dana Brook said: Red flag of bad therapy #9 : Insurance Fraud […]

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